Introduction:
Evaluation of the effectof educational intervention on early initiation
of breast feeding in full term normally delivered baby 1 & 6
months andfactors affectingbreast feeding. Methods:
interventional study with subjects as mothers with vaginal delivered
newborns excluding preterm, VLBW/ LBW / /IUGR babies, newborn with
medical or surgical problems and whose child didn’t survive
Cases were pregnant women attending antenatal clinic of KRH (n=124) and
controls were mothers delivered at government hospital except
KRH.(n=120). Mothers counseled antenatally and helped for initiation of
breast feeding immediately after birth and again counseled individually
at discharge, on follow up at end of1st and 6months. In control group
breast feeding practices were recorded at 1 and 6 months after birth
without any counseling. Results:
There were 76.8% (n = 80) mothers who had early initiation of breast
feedingin interventional groupcompared to 10.56% (n = 12) in
non-interventional group with odds ratio of32. 93 and 83%mothers in
interventional group were practicing EBF (p = 0.01)against only 63 %,
and 49% mothersat 1 and 6 months respectively in non-interventional
group. Effect of counseling in cases for EBF was more in
primiparous(70.83% and 91.30%) than in multiparous (29.16% and 60.41%)
at 1 and 6 months respectively (p = 0.01and 0.04). Conclusion:
counseling antenatally and at regular intervals significantly increase
early initiation and sustainedexclusive breast feeding. This influence
primiparous mothers more.

Breastfeeding is the normal way of providing young infants with the
nutrients they need for healthy growth and development. Virtually all
mothers can breastfeed, provided they have accurate information and
support of their family, the health care system and society at large.
Exclusive breastfeeding is recommended up to 6 months of age.
Breastfeeding is the ideal food for newborns and infants, providing
them with all the nutrients they need for healthy development. If every
child was breastfed within an hour of birth, given only breast milk for
their first six months of life, and continued breastfeeding up to the
age of two years, about 800 000 child lives would be saved every
year[1]. Adequate breastfeeding counseling and support are essential
for mothers and families to initiate and maintain optimal breastfeeding
practices[2].Early breastfeeding within 1 hour and exclusive
breastfeeding for the 6 months are the key interventions to achieve
millennium development goal 1 (MDG) and MDG 4, which deal with
reduction in child malnutrition and mortality. In India, effective
implementations of these interventions are yet to be achieved. National
Family Health Survey- 4 data show that the initiation of breast feeding
within 1 hour is only 34.5% while the exclusive breast-feeding rates in
children < 6 month is only 58.2%[3]. Counseling is very
important in antenatal period for early initiation of breast feeding
& sustained exclusive breast feeding.

Method

This study was a prospective non-randomized interventional study.
Ethical approval was obtained from Ethical Committee, Gajra Raja
Medical College, Gwalior. Informed and written consent of mothers was
taken prior to enrollment in the study. Total 244(calculated by
n=z21-@/2p(1-p)/d2) mothers were participant for study.Onegroup(n=124)
was given educational intervention for breast feeding benefits(as per
the IYCF Guidelines)who attended Anti natal checkupand delivered in
Kamla Raja Hospital and werecalled interventional group and other
group(n=120) who were delivered in another hospital(after ethical
clearance) were not given any intervention taken as non-interventional
group. Educational intervention was in form of counseling about the
benefits and importance of early initiation of breast feedingbefore
delivery in the antenatal ward in third trimesterthen after delivery
and 1 month and 6 months of age, assistance in startingbreast feeding,
motivation to continue exclusive breast feeding up to optimal
period.This group was helped in starting breastfeeding within 1 h after
delivery and during their stay at hospital and counseled at discharge.
Counseling skills was adapted according to infant and young child
feeding (IYCF) practice guidelines [4]. Early initiation of
breastfeeding is defined as breast feeding startedwithin the first hour
of life andExclusive breastfeeding is defined as the infant exclusively
receives breast milk and no any additional food or drink, not even
water. Follow-up was carried out in newborn well baby clinic at the end
of 1st and 6 months. Effect of counseling was also compared in
primiparous and multiparous mothers enrolled in interventional group
[Table 3]. Non-interventional group received all the information about
breast feeding as per the standard protocol of the hospital and
received no counseling by the investigator at any time during the
study. Support for breastfeeding in the non-interventional group
included the usual verbal encouragement provided by the maternity ward
staff members, a general health assessment and an evaluation for
evidence of successful breastfeeding behavior by the investigator. They
were also followed at the end of 1st and 6thmonth and breast-feeding
practices recorded.

Results

In interventional group out of 124 enrolled, 28 were excluded based on
exclusion criteria and 96 mothers participated in study. Out of96, 6
and 8 were lost tofollow-up at 1 month and 6 months respectivelyso
finally 82 mothers were taken for final analysis [Fig.1].
Innon-interventional group, out of 120 enrolled mothers, 32 were
excluded. 88 mothers were taken in study but9 and 12 were lost to
follow up at 1 and 6 months respectively so in group II finally 67
mothers were taken for final analysis [Fig.1].

There were 76.8% (n= 80) mothers who had early initiation of
breast feeding in interventional group compared to 10.56% (n = 12) in
non-interventional group with odds ratio of 32. 93% and 83% mothers in
interventional group were practicing EBF at 1and 6 monthsrespectively(p
= 0.01)against only 63 % and 49% motherswere practicingEBFat 1 and 6
months respectively in non-interventional group. Effect of counseling
in interventionalgroup for EBF was more in primiparous mothers (70.83%
and 91.30% at 1and 6 months, respectively) than in multiparous (29.16%
and 60.41% at 1 and 6 months, respectively) (p = 0.01 and 0.04)[fig 2].
Analysis showed that literacy rate in mothers in interventional group
was more (75%) compared to those in non-interventional group (50%).
[Table-1].

Table-2: Distribution
pattern of mean weight gain on follow up significant in interventional
group

Weight (in kg)

Birth

1 month

6 month

Interventiongroup

2.66±0.39

3.61±0.48

5.79±0.52

Noninterventiongroup

2.49±0.36

3.07±0.41

4.86±0.78

Mean weight gain

0.27±0.03

0.54±0.07

0.93±0.26

p value

0.01

0.0006

0.00001

t value

2.78

4.93

5.45

In interventional group weight gain in new born at 1 month
3.61±0.48 (in kg), was significantly higher ascompared to
weight gain in non-intervention group at 1 month(3.07±0.41)
with P value 0.0006, and at 6 months weight gain washigher in
interventional group with p value 0.00001[Table 2]

Discussion

The present study was undertaken to observe the morbidity pattern and
breast-feeding practices in 244 newborns in Kamla Raja Hospital as well
as other government maternity homes of Gwalior divided in to 2 groups
intervention group an non-intervention group The infants, so registered
were periodically followed at 1 month and 6 month of age. At each
follow up there feeding history was reviewed, nutritional status was
assessed through anthropometry and clinical examination was done to
discover any disease present and history regarding breast practices was
recorded. We observedin this studyintervention group primiparous
mothers were more effectively counseled for early initiation of breast
feeding as comparison to multiparous mothers. Dedicated lactation
specialists may play a role in providing education and support to
pregnant women and new mothers wishing to breastfeed to improve
breastfeeding outcomes [5].

According to National Family Health Survey-3 data, about 20 million
children are not able to receive exclusive breastfeeding (EBF) for the
first six months, and about 13 million do not get good, timely and
appropriate complementary feeding along with continued breastfeeding
[3]. Over the past several years, India has failed to witness any
remarkable progress in infant feeding practices, with only a small
increment being recorded in EBF rates amongst infants 0-6 months of age
– from 41.2% in 1998-99 (NFHS-2) to 46.3%% in
2005–2006 (NFHS-3)to 58.2% in 2015-2016 (NFHS-4)[3]. In over
study this 93% and 83%mothers in interventional group were practicing
EBF at 1and 6 monthsrespectively(p = 0.01)against only 63 % and 49%
motherswere practicingEBF at 1 and 6 months respectively in
non-interventional group. In other study the rate of early initiation
of breastfeeding stands abysmally low at 24.5%, while the median
duration of EBF among last-born children is as brief as two months.
Further, the rate of EBF drops progressively from 51% at 2-3 months of
age to 28% at 4-5 months of age [4].

In a recent Annual Health Survey conducted in India from 2010 to 2013
covering all the 284 districts (as per 2011 census) of 8 Empowered
Action Group (EAG) States (Bihar, Uttar Pradesh, Uttarakhand,
Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha and Rajasthan and
Assam) [6], the percentage of children breastfed within one hour of
birth was observed to vary from 30% in Bihar and Uttar Pradesh to
around 70% in Assam and Odisha. Children exclusively breastfed for at
least 6 months ranged from 17.7% in UP to 47.5% in Chhattisgarh [4]. In
this study early initiation of breast feeding in interventional group
was more (76.8%) compared to those in non-interventional group
(10.56%). Early breastfeeding within 1 h and exclusive breastfeeding
for the first 6 months are the key interventions to achieve millennium
development goal 1 (MDG 1) and MDG 4, which deal with reduction in
child malnutrition and mortality respectively [7]. In India, effective
implementation of these interventions is yet to be achieved. National
Family Health Survey-4 data show that the initiation of breastfeeding
within 1 hour is only 41.6% while the exclusive breastfeeding rates in
children <6 month is only 54.9% [3]. It has been estimated that
initiation of breastfeeding within an hour of birth can save 1 million
babies [8]. Promotion of early initiation of breastfeeding has
potential to make a major contribution in achievement of healthy child
survival MDG. About 16% of neonatal lives could be saved if all infants
were breastfed from day 1 and 22% if breastfeeding started within the
1st hour [1]. This has particular relevance in our country, where
neonatal and infant morbidity and mortality rates are high.

Counseling has an inevitable role in successful and sustained exclusive
breastfeeding along with early initiation of breastfeeding. Therefore,
this study was planned to assess the effect of counseling on breast
feeding practices, especially early initiation and sustained exclusive
breast feeding (EBF). Every mother, especially the primipara, should
receive support from doctors, nursing staff or community health workers
(in case of non-institutional birth) with regard to correct
positioning, latching and treatment of problems, such as engorgement,
nipple fissures and delayed ‘coming-in’ of milk. If
available, dedicated skilled supports like Lactation Consultants/
Mother Support Counselors/ Peer Counselors should be facilitated to
support the mother in the antenatal, immediate postnatal period, post
discharge follow-ups and in neonatal care units. Mothers need skilled
help and confidence-building during all health contacts and at home
through home visits by trained community worker, especially after the
baby is 3 to 4 months when a mother may begin to doubt her ability to
fulfill the growing needs and demands of baby[4]. Early initiation and
EBF was strikingly more in primiparous, which showed that these mothers
could be easily motivated when approached during antenatal and
immediate postnatal period to emphasize and teach them the importance
of early initiation and sustained EBF along with technique of breast
feeding. Multiparous mothers, due to their previous experience in
breast feeding, are difficult candidates for counseling for early
initiation of breast feeding and also for sustained EBF in later life.
A previous study also reported same results [9]. Similarly, a study of
selected Mexican hospitals showed that counseling combined with babies
staying with their mothers, significantly increased full breastfeeding
among primiparous mothers [10]. Similar results were obtained in study
done by Agre et aland Holmes et al. [11,12]. However, Ekström
et al. concluded that parity had no significant influence [13].

common reasons for early breastfeeding discontinuation was early
discharge from hospital. Which could be overcome if the woman was
informed antenatally and onperiodic basisabout the benefits of
breastfeeding and prepared mentally for exclusive breastfeeding. This
studyrevealed that antenatal breastfeeding education and postnatal
lactation support, can significantly improve rate of early initiation
of breast feedingand rates of exclusive breastfeeding for optimum
period. Existing support for breastfeeding is inadequate in the
population studied and needs to be strengthened. Informing all pregnant
women about the benefits and management of breastfeeding should be a
priority during antenatal visits. Primipara mothersare mostimportant
target group for counseling because they are more adaptive. The group
counseling was foundmore effective than individual mother counseling.

Conclusion

Early initiation of breast feeding after birth i.e. 1 hr prevents
morbidities and promote healthy survival of infant & optimal
weight gain in infants. Counseling in antenatal periodis very effective
in early initiation of breast feeding. Primiparous mother are more
energetic as comparison to multiparous mother about breastfeeding

What this study adds: Mothers/
caretakers/attenders should be counselled in antenatal period to ensure
hundred percent early initiation of breastfeeding.

Regular and periodic counselling forsustained breastfeeding upto six
months of life and beyond that.

6. Presentation on Annual Health Survey Fact Sheet Key
Findings. New Delhi. Office of the Registrar
General and Census Commissioner, Ministry of Home Affairs, Government
of India;
2011.Availablefrom:http://www.censusindia.gov.i.n/2011,Common/AHSurvey.html.
Accessed July 11, 2015.